Biomedicine in an unstable place

Infrastructure and personhood in a Papua New Guinean hospital

Alice Street

— Reviewed by Courtney Addison

Alice Street, Biomedicine in an Unstable Place: Infrastructure and Personhood in a Papua New Guinean Hospital. Duke University Press, 2014. Paperback, 304 pp., $24.95. ISBN: 978-8223-5778-0.

In the prologue to her monograph, Biomedicine in an Unstable Place, Alice Street shares the story of William Gambe. This opening expertly foreshadows the rest of the book: as William becomes increasingly unwell, we see the interplay of kinship tensions and sickness, resource shortages and diagnostic uncertainty, and a pervasive concern about feeling invisible. Street’s ethnography is based in Madang Hospital, Papua New Guinea, and is based on fieldwork spanning ten years. The book is an excellent contribution to the canon of hospital ethnographies, and its place-based approach illuminates grounds on which multiple worlds collide. Madang Hospital sees constant frictions between medical practice and scientific research, kin and professional relationships, state-making projects and colonial histories. Despite this capacious subject matter, this work feels cohesive and makes clear contributions to existing theoretical, ethnographic, and political conversations.

In the Introduction, Street comments that surprisingly few hospital ethnographies engage with postcolonial problems. She sets out to remedy this with a close examination of the historical processes that created both Madang Hospital and the Papua New Guinean state that exists today. Thus we see how Papua New Guinea, like many other colonies, was seen as a valuable site for medical experimentation by both German and Australian rulers, and how it later became an object of international development agendas. Today the country is again a popular site amongst overseas researchers. These people bring in money and infrastructure, but at the same time serve to sustain a devastating disparity between well-provisioned medical research and under-resourced public health, both of which coexist in the very same spaces. Though the Papua New Guinean state and its hospitals may seem to be failing, Street provides an important corrective by highlighting the historical damages from which this legacy arose.

These connections between historic Papua New Guinea and the country’s contemporary predicament provide a structural bracket for the ethnographic body of the text. Particularly compelling here is the attention paid to the various relational forms that manifest – or fail to manifest – in the hospital. Street elaborates this through a fine synthesis of Strathernian theorizing of Melanesian personhood and her own ethnographic material, rife with worries and social maneuvering. Thus she shows how patients immerse themselves in projects of recognition by trying to present themselves in forms that elicit responses from doctors or kin. For example, when patients described to her their illness as sik bilong marasin (sickness relevant to biomedicine) rather than sik bilong ples (village sickness), Street reads this as an attempt by them to enlist her supposed white person’s expertise (p. 32). Connections with other people come to be mediated by what Street calls ‘relational technologies’. Patients pursue X-rays, for example, as a way of rendering themselves in a form that doctors would be inclined to treat. Here, a Melanesian relationality intersects with a biomedical reification of bodies and sickness, allowing Street to argue that, in Madang, ‘the relationships through which persons are conventionally established as either “dividuals” in Melanesian kinship or biological “things” in EuroAmerican biomedicine remain inherently unstable’ (p. 30). 

Running through Biomedicine in an Unstable Place is an idiom of visibility. A primary concern of many who work in or pass through the hospital is that they are invisible to the people by whom they need to be noticed. Patients worry that doctors don’t see their suffering; nurses worry that the state does not see the difficulty of their work. By showing how doctors and patients both struggle to make manifest illness and care amidst inadequate resources and infrastructure, Street problematizes critiques of the clinical gaze. As patients strive to have X-rays made, she shows how recipients of this gaze are not necessarily subjugated, but can present themselves in ‘persuasive forms’ that demand certain types of seeing. Moreover, the opacity of illness in a place where basic medical technologies are absent or non-functioning elicits new ways of seeing and acting. There is a resultant pragmatism at work in Madang: one doctor, whose lab cannot run his tests until the dye arrives, marches to the corner store to buy calligraphy ink and does it himself. Doctors deem patients ‘generally sick’ when they cannot achieve a clear diagnosis, a compromise that might not meet the standards of their international peers but that allows them to provide treatment as best they can, even if they do not quite know which disease they are treating. 

I would have liked to see the discussion on ‘making visible’ extended just a little further. It seems to me that there may be some important insights to be made if one considers the instances in which visibility is not sought, but imposes itself nonetheless. What, for example, of the doctor who nods nervously and hurries past a patient calling for his help (p. 136)? What of another patient’s wife, who feels herself exposed before the other inhabitants of her husband’s ward (p. 6)? What of the nurse who retreats to her office when the glasman, the local healer, intrudes into the ward at the request of a patient (p. 5)? In these cases, witnessing implies responsibility for the seer, while being seen suggests revealing some vulnerability. I would like to have seen if thinking in this direction could have enriched Street’s treatment of visibility and the work of ‘making visible’.

Biomedicine in an Unstable Place is an important text of impressive quality. The volume makes a valuable contribution to Melanesian studies, medical anthropology, and postcolonial studies. More importantly, as Street notes in her introduction, most of the world’s people now encounter biomedicine in ‘peripheral institutions’ like Madang Hospital; more attention to the forces at work in such places is warranted. In her discussion of the work that goes into ‘making visible’, Street reflects on her own role, representing this place and people, making them visible to her readers. She hopes that through ‘good description’ (p. 33) she might communicate the difficulties and possibilities one encounters in Madang (and no doubt in similar hospitals around the world), and perhaps in doing so suggest ‘some ways in which that reality could be made better’ (p. 34). In the writing of this book she has created a persuasive form of her own, one that engages the recognition of her readers and invites response.

About the author

Courtney Addison is a doctoral candidate at the University of Copenhagen. She is a member of the Department for Food and Resource Economics, and resident anthropologist on the Consortium for Designer Organisms. She is currently conducting fieldwork on human gene therapy at two European hospitals. Her research investigates what is at stake for patients and practitioners of human gene therapy, and poses questions of value, ethics, and social belonging.